The real mortality benefit of bundled therapy lies in a consistent and systematic treatment protocol applied to every septic patient. Results of the Surviving Sepsis Campaign showed that bundled therapy for management of sepsis decreased mortality from 37% to 30.8%.7 Mortality decreased the longer an institution used standardized bundle therapy.8 Further, bundle therapy saves hospital and health care resources.5 Studies continue to show that bundled therapy is underutilized in septic patients. Frequently cited barriers include unavailability or expense of central venous monitoring devices, lack of nursing staff able to operate central venous pressure monitoring, and challenges in identifying septic patients.9 Noninvasive sepsis management can help with all of these cited barriers.
Explore This IssueACEP News: Vol 31 – No 04 – April 2012
The growing literature describes sepsis management that provides an alternative to the invasive central venous pressure (CVP) and mixed-venous oxygen saturation monitoring central to
early goal-directed therapy (EGDT). Noninvasive therapy focuses on using dynamic ultrasound assessment of inferior vena cava (IVC) collapsibility to estimate intravascular volume status as an alternative to invasive CVP monitoring. Also, this model follows lactate to measure response to therapy versus mixed-venous oxygen levels. While the noninvasive management of sepsis is not supported by a body of evidence as robust as that for invasive monitoring, the existing literature is compelling.
Indications for noninvasive sepsis management include:
- Lactate over 4 or MAP less than 65 mm Hg after 2 L 0.9 NS bolus.
- Multiple large-bore (up to 3 × 18 g) IV access that can run fluids and multiple antibiotics simultaneously.
- Goal of treatment is curative.
- Patient habitus allows visualization of the IVC.10 Contraindications for noninvasive sepsis management include:
- Poor peripheral access.
- Poor ultrasound visualization of IVC.
- Vasopressor requirement.
- Severe septic shock.
- Pulse oximetry less than 90% on supplemental oxygen.
- Respiratory distress.
Table 3. Ultrasound Assessment of IVC Collapsibility
- Obtain a long axis view of the IVC by placing a curvilinear abdominal probe parallel with the spine below the subxyphoid, with the probe indicator toward the patient’s head.
- Slide 1-2 cm to the right to bring the IVC into view.
- Aim slightly toward the heart to bring the RA into view. Image should have the RA clearly leading into the IVC with the liver in view.
- Measure (either visually or in M-mode) 1 cm below the hepatic vein or 2-3 cm from the RA. A patient who is fluid responsive will have significant respiratory variation with each breath and will have roughly 50%-100% collapse of the IVC as negative intrathoracic pressure is generated with each breath.
- Resuscitate to the point where you visualize only 30% collapse of IVC.
If habitus limits view of the IVC, use the liver as an acoustic window, aiming from the RUQ toward the head. The solid nature of the liver will conduct sound waves more readily. If bowel gas obscures view, put pressure on the ultrasound probe and shake with low-amplitude, high-frequency oscillations to encourage peristalsis.